Hundreds Affected in ‘Unprecedented’ Ebola Outbreak

By Angela Griffith

The ongoing Ebola epidemic in Africa is “unprecedented” due to its high mortality rate (up to 90%), geographic spread (at least 5 countries have reported cases of the disease, which has spread to urban areas as well), and difficulty enforcing quarantines that would reduce the spread.  As with many outbreaks, the factors involved are complex and wide-ranging.

We can address the issues contributing to the outbreak by capturing them in a Cause Map, or visual root cause analysis. This intuitive method ties impacted goals to cause-and-effect relationships, allowing development of solutions to all aspects of an issue.

First we begin with the impacts to the goals.  The outbreak began in Guinea at some point in early 2014, but was reported to the World Health Organization (WHO) on March 23, 2014.  The outbreak is still ongoing and has impacted Guinea the most, but has also spread to neighboring countries.  The strain involved is the Zaire Ebola virus, which is spread by bodily fluids.

At the date of publication, the virus has killed at least 101 out of 157 infected in Guinea alone.  The infections and deaths, as well as the spread of the disease, can be considered impacts to the public safety goal.  This is the first outbreak to have impacted urban Guinea, though there have been dozens of outbreaks in Africa over the past 40 years.

“Why” questions are used to determine the cause-and-effect relationships that resulted in the impacted goals.  Death typically results from bleeding or shock, which occurs due to infection with the virus and insufficient treatment. Infection results from the initial transmission (caused by eating raw infected meat), and the spread of the disease.  The spread in this case has resulted from the unusual migratory pattern, both because of the easy and frequent travel between countries but also due to an as-yet-unknown factor.  Normal outbreaks involve a much smaller geographic area.) Victims are contagious for a long time, meaning the disease is easily spread, and it has been difficult to enforce quarantine, because of mistrust of local authorities and foreign aid workers.  According to Stéphane Hugonnet  of WHO, “The mortality rate is extremely important.  Nine out of ten patients will die.  If we look at this from the population’s perspective, why would you go to a hospital if you have almost zero chance of getting out of it.”  However, with effective care, there is a chance of surviving Ebola.

However, providing that care is another challenge.  There is no cure for Ebola, possibly because financial incentives to develop a cure for a rare disease that primarily strikes poor African villages isn’t there. Care essentially involves keeping a person alive long enough for their body to be able to fight back, difficult in a country that has 0.1 physicians for every 1,000 people fighting a disease that rapidly replicates and – through an unknown mechanism – disables the immune system.

So what’s being done to end this outbreak?  Medical teams from Doctors without Borders (or Médecins Sans Frontières) and WHO have been dispatched to the area.   These medical teams may include anthropologists, to better address local concerns regarding the disease.  WHO has also recommended limiting personal contact and a on raw bush meat.  Meanwhile, researchers are working on a vaccine to prevent  transmission of Ebola.  It is hoped that these steps together will end this outbreak – and prevent future outbreaks as well.

To view the Outline, Cause Map and Solutions, please click “Download PDF” above.

CDC Finds that 1 in 25 Patients Acquire an Infection While in the Hospital

By Kim Smiley

A recent headline from the New York Times reads “Infections at Hospitals Are Falling, CDC Says”.  That sounds like fantastic news right?  Well, what about this one from the same day from the Washington Post: “One in 25 patients has an infection acquired during hospital stay, CDC says.”  One in 25 doesn’t seem like great odds to me.  The two headlines give very different impressions of the problem, so which one is right?

The truth is that both statements are accurate, but neither tells the complete story.  To really understand the situation, you need to read a lot more than just the headlines. This is a good analogy for what happens in meetings every day.  Something goes wrong and everybody thinks they know what THE problem is or what is THE root cause.  Many times when people argue they aren’t really in disagreement, they are just focused on different parts of the same puzzle.

Building a Cause Map, a visual format for performing a root cause analysis, can help reduce miscommunication.  The first step in the Cause Mapping process is to fill in an Outline.  The top of the Outline lists the basic background information.  At the bottom of the Outline, there is space for listing the specific impacts to the overall goals.  People may argue about what THE problem is, but it’s hard to argue when specifically listing how the problem impacts goals.  For example, most people would agree that increased cost of healthcare is an impact to the overall economic goal of a hospital.  It may sound counterintuitive, but adding detail helps clarify the situation, when defining the problem and when actually determining what went wrong.

In the case of those headlines listed above, both refer to a recent study by the Center for Disease Control and Prevention that found that about 1 in 25 patients in US hospitals in 2011 acquired at least one infection based on data from 11,282 patients treated at 183 hospitals in 10 states.   (The total number of patients who acquired at least one infection is over 700,000.) The study estimated that around 75,000 of these patients died, but didn’t provide information on whether the deaths directly resulted from the infections.  The study also didn’t include nursing homes, emergency departments, rehabilitation hospitals and outpatient treatment centers.  Previous estimates put the number of infections each year at 2.1 million in the 1970s and 1.7 million from 1990 through 2002. The rate of infections also varies widely from hospital to hospital.  There is uncertainty in the data available, but the trend seems to be going in the right direction, even though the problem of hospital-acquired infections remains significant.  Before working to reduce the risk of a problem, it’s important to lay out all the facts and understand what exactly the problem is.  That generally requires more than a simple statement, which is why the Cause Mapping uses a formal Outline to define a problem.

After the Outline is completed, the next step is to analyze the issue by building a Cause Map by asking “why” questions starting with one of the impacted goals.  Hospital acquired infections are an impact to the patient safety goal so we could begin by asking “Why are patients getting infections in hospitals?”  This occurs because they are exposed to a pathogen.  Why?  There are pathogens at the hospital because many sick people are there for treatment.  Inadequate cleanliness also plays a role.  Additionally, the pathogen is able to infect the patient.  You would continue asking questions to determine why patients are being infected until you reach the desired level of detail.  Generally, the bigger the problem, the greater level of detail is needed.

To view a completed Outline and a Cause Map of this issue, click on “Download PDF” above.

US Doctors Issue Statement That Mothers Should Avoid Water Births

By Kim Smiley

The number of water births in the United States has been increasing in recent years and controversy over their safety continues to rage.  The latest development is that the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recently issued a joint statement saying that water births are not recommended and should be avoided, but some midwives and mothers disagree and adamantly defend the benefits of birthing in water.  The doctors agree that soaking in water during early labor may make the experience more pleasant for mothers, but feel that actual birth should be outside of the birthing tub.

One of the issues is that the benefits of water birthing are difficult to prove and the potential risks are difficult to quantify .  Some mothers believe that birthing in water helps relieve pain and can aid in a drug-free delivery.  Supporters of the practice also think that birthing in water can shorten labors, which reduces stress on the mother and the baby.  Some midwives have also expressed a belief that water births are gentler on babies, saying that many do not cry when they are born.  It’s difficult to definitively study the impacts of water births because birth outcomes depend on so many factors and you can’t do a double-blind study because it’s pretty much impossible to have a placebo for a water birth.

There have been reports of individual cases where something went wrong during a water birth, but there is little information on how often this occurs.  There is general agreement that complications are rare, but the doctors  releasing the statement feel the risk of complications outweighs the benefits.  The most serious concern is the baby drawing its first breath underwater, which could lead to breathing issues and even drowning.  There is also a risk of umbilical cord ruptures since the baby must be brought to the surface relatively quickly and the cord may be too short.  There is also increased risk of infection for the mother and baby since they are both exposed to potentially contaminated water because birth can get messy.

Until now, there has been little formal guidance provided about water births.  Providing more information for expectant mothers is a great first step, but disagreement between medical professionals about birthing methods can add confusion to an already stressful time.  Until more studies are done to provide a better understanding of the risks involved, women will have to rely on their own judgment and the guidance of their healthcare provider.

To view an Outline and Cause Map of this issue, please click “Download PDF” above.

New Studies Shed Light on Statin Side Effect Concerns

By Kim Smiley

Usage surveys have found that the majority of people prescribed statins in the United States discontinue using them within a year. The number one reason stated by patients for stopping statin use is concern with side effects.

This issue can be analyzed by building a Cause Map, a visual method for performing a root cause analysis.  The first step in the Cause Mapping process is to define the problem by filling an Outline with the basic background information (who, what, when, where, etc.).  Additionally, the Outline is used to capture how the problem impacts the goals so that the magnitude of the problem is well understood.   Once the Outline is complete, the analysis is done by building a Cause Map by asking “why” questions to find the causes that contribute to an issue.

For this example, the fact that patients aren’t taking prescribed statins is an impact to the patient goal.  This occurs because patients were prescribed statins and they are not using them.  Looking at each cause individually, let’s first ask why patients were prescribed statins.  A physician wrote a prescription for statins because the patient was considered at risk for heart disease and statins can reduce the risk of heart disease.  Statins have been shown to reduce cholesterol levels in the blood and high cholesterol can lead to blocked arties that can contribute to heart disease.  Cholesterol is reduced because statins inhibit an enzyme in the liver that controls cholesterol production in the body and the majority of cholesterol is produced by the liver.

So the question that still needs to be answered is why aren’t patients taking their statins if they can reduce their risk of heart disease?  The most significant reason that patients are discontinuing statin use is because they are concerned about side effects and the concerns haven’t been adequately addressed. Patients are concerned about side effects because they believe they have experienced side effects or they are generally worried about potential side effects.

Like most other medications, statins can have serious side effects, such as liver injury, cognitive impairment and potential for muscle damage (especially when combined with certain other medications.  According to the U.S. Food and Drug Administration, the value of statins in preventing heart disease has clearly been established and the benefits outweigh the risks, but one of the reasons that patients are concerned about side effects is that there are very outspoken critics of statins that do not agree with this assessment.  For the purpose of this example, we will assume that the FDA is correct that patients would benefit from taking statins if they are prescribed and that it is in fact a problem if patients discontinue using stating when their physicians have recommended them.

The final step in the Cause Mapping process is to come up with solutions that can be implemented to help reduce the risk of a problem occurring in the future. So how can the risk that patients will discontinue statins be reduced?  One possible solution would be to give patients reliable information that shows that statins are relatively safe and are effective at reducing the risk heart disease.  If patients believe that the benefits of statins outweigh the risks, they will be significantly more likely to take them.  More information is becoming available as researchers continue to study the benefits of statins and the frequency and severity of side effects.  For example, a recent study that used 83,000 patients and randomized statin therapy and a placebo found that “only a small minority of symptoms reported on statins are genuinely due to the statins: almost all would occur just as frequently on placebo”.  With more data about the effectiveness of statins and the accurate information the risks associated with them patients can make decisions based on real data and better determine if they should keep taking the statins.

To view the Outline and Cause Map, please click “Download PDF” above.

13-Inch Surgical Tool Left In Patient for Months

By Kim Smiley

For about two months after surgery to remove a large malignant tumor Donald Church complained of severe pain.  Initially, he was told that it was normal pain associated with recovery from a major surgery, but an x-ray was ordered after his physician felt a lump in his abdomen.  The x-ray revealed that a malleable retractor similar in size to a ruler had been left inside his body after surgery.  A second surgery was done to remove the tool.  Mr. Church is not expected to suffer long-term health consequences and received a $97,000 settlement.

A Cause Map, a visual format for performing a root cause analysis, can be built to help understand how this issue happened.  Once all the causes that contributed to an issue are found, potential solutions can be found and the most promising can be implemented to help reduce the risk of a similar issue reccurring.

So how did this happen?  How does a large surgical tool get left inside a patient?  This occurred because the patient needed surgery to remove a tumor, the malleable retractor was used during the surgery and the surgeons were unaware that the tool remained inside the patient. (These causes are vertical on the Cause Map with “and” between them because all 3 were necessary for the issue to happen.)  A malleable retractor was used while the wound was being closed to help protect the organs under the wound from possible puncture from the suturing needle.

The surgeon was unaware that the tool was inside the patient because he couldn’t see it and there wasn’t an adequate system in place to manage surgical tools.  Malleable retractors are normally held partly out of the wound, but it had slipped entirely inside the wound during the surgery.  Once the tool was out of sight, it was forgotten.  While many hospitals have requirements to formally count surgical tools as they enter and leave the operating room to ensure that all are accounted for, there wasn’t a policy in place in the facility that performed the surgery at the time.  With no formal system to track tools, there weren’t any easy indications to the operating team that there was a problem.

While this is a particularly egregious example, there are an estimated 4,000 cases of retained surgical items each year in the United States. Better solutions need to be found to reduce the risk of this preventable and potentially deadly problem from happening.  A simple solution to reduce the risk for retained surgical items is to institute a formal procedure for counting surgical supplies and tools before and after surgery.  Simple manual counts are a first step, but errors still occur, especially in the often hectic and stressful environment in an operating room.  Some hospitals use a visual inventory system where tools are brought in a special storage bag with an individual compartment for each item.  As items are done being used they are put back into their specific spot.  If all compartments are full, everything is accounted for so it’s easy to tell if something is missing.

Another solution that is gaining in popularity is use of an electronic tracking system.  The most common use of electronic systems is to track sponges, which are by far the most common object left inside patients.  Each sponge has an electronic tag and the patient is scanned after surgery to verify that none were left behind.  Sponge tracking systems add about $8 to $12 to the cost of each surgery and have dramatically reduced the number of retained sponges when used.

To view a high level Cause Map, click on “Download PDF” above.

New Study Finds that Dirty Stethoscopes May Spread Germs

By Kim Smiley

It’s been well documented that washing hands can prevent infections and in the same vein some researchers are now asking questions about potential contamination risks posed by stethoscopes and other small medical equipment used to examine multiple patients. In a recent study, stethoscopes were tested after they were used to examine patients and most were found to have bacteria on them.  Unlike the guidance provided for hand washing, there are currently no guidelines that require physicians to disinfect their stethoscopes between patients.

This issue can be analyzed by building a Cause Map, a visual format for performing a root cause analysis.  In a Cause Map, the causes that contribute to an issue are laid out to show the cause-and-effect relationships to aid in understanding the role the causes played.  The first step in the Cause Mapping process is to fill in an Outline with the basic background information for a problem such as the location and time it occurred.  Additionally, how the issue impacted the organizational goals is documented on the Outline.  The possibility of patient exposure to bacteria is an impact to the safety goal in this example.  Once the impact to the organizational goals is defined, the Cause Map is built by asking “why” questions.

Why is there a risk of patient exposure to bacteria?  This is happening because a contaminated stethoscope may be placed on a patient’s skin.  Stethoscopes are commonly used to listen to a patient’s heart and lungs and they work best when placed directly onto the skin.  Stethoscopes may get contaminated from being used on a person with bacteria on their skin and stethoscopes are not necessarily cleaned between uses.  Stethoscopes aren’t always cleaned between uses because there are currently no guidelines requiring it.  There aren’t any guidelines because it hasn’t been clear if they are needed.  There has been limited research done to understand the issue and determine how much of a risk of illness a contaminated stethoscope may pose, especially if used on healthy skin.

The new study is a good early step in understanding the issue, but it was a relatively small study and a larger scale study may be needed in the future.  The study “Contamination of Stethoscopes and Physicians’ Hands after a Physical Examination” looked at the stethoscopes used by three physicians as they examined a total of 83 patients in a Swiss hospital.  The researchers found bacteria on the stethoscope after 71 of the patient examinations.  It’s also difficult to determine whether bacteria on stethoscopes is responsible for spreading bacteria and whether it has actually caused illness.

The final step in the Cause Mapping process is to come up with solutions that can reduce the risk of the problem recurring in the future.  One good thing about this particular issue is that the solutions are relatively easy and cheap.  Physicians who are concerned about the cleanliness of their stethoscopes can either give them a give clean with disinfectant between patients or use disposable covers that are already commercially available.  Guidelines about cleaning stethoscopes are likely years in the future, but you can always ask your physician about the issue or to clean the stethoscope if you are concerned.

Failure to Read Back Physician Order Causes Patient Death

By Angela Griffith

A patient suffering from pneumonia required a bedside bronchoscopy in a California hospital.  In order to provide sedation for the procedure, the physician performing the procedure requested a dose of Versed.  Although the actual dosage requested was not recorded, the nurse gave the patient 2 milligrams via IV and, a minute later, another 2 milligrams.  The maximum published dose for Versed is 1.5 milligrams over no less than 2 minutes.

Because of the bedside scenario and the verbal order for medication, the nurse was required by hospital policy to repeat back the order.  He did not, so there was no opportunity for the physician to realize the error.  Within a few minutes, the patient stopped breathing and was administered CPR.  However, the patient never regained consciousness and died nine days later.

We can look at this issue within a Cause Map, a visual root cause analysis that addresses all the cause-and-effect relationships that resulted in the issue being investigated.  The analysis begins with the impacted goals.  In this case, the patient safety goal is impacted due to the patient death.  The failure to follow hospital policy regarding repeat back of verbal orders is an impact to the compliance goal.  The patient services goal is impacted by the overdose that was administered.  The overdose resulted in extra care required for the patient, an impact to the labor goal.  As a result of the issue, the hospital was fined $50,000 by the California Department of Public Health.  (Click here to read the report, which was used to create this blog.)

Beginning with an impacted goal and asking “Why” questions adds more detail to the analysis.  In this case, the overdose occurred due to the need for Versed and the larger than ordered dose.  The larger than ordered dose resulted from a miscommunication between the physician, who ordered the Versed, and the nurse, who administered it.  The nurse did not repeat back the order as required, and the physician did not request a repeat back.  Although the requirement was apparently for the person receiving the order to repeat back, patient safety is everyone’s responsibility.  Pausing the procedure to ask for a repeat back would have likely saved the life of this patient.

Not mentioned in the analysis was the conditions under which the order and procedure were performed.  Clearly ability to hear was a concern.  A study published in May of 2013 determined that background noise in the operating room can result in difficulty in communication between team members, not only by affecting team members’ ability to hear each other, but could also impair an individual’s ability to process auditory information.  Other studies have found that other environmental factors can impact medical errors.  Specifically, one study found that most medication errors were more likely to occur when the previous 30 minutes were hectic and involved staff member distraction.  It is unclear how much of a role the environment played in this case.

The hospital involved in the issue focused efforts on ensuring hospital policies were re-emphasized.  While this is a typical response in this type of situation, the training efforts must ensure that the importance of the policies is emphasized, possibly by using lessons learned from actual cases to demonstrate the risk of these policies not being followed.  Additionally, all staff must take responsibility for patient safety.  Even though the policy required repeat back by the nurse, other staff members involved with the procedure should have played a role in ensuring that the communication between members was adequate to ensure patient protection.

Want to learn more? See our webpage about medication errors in medical facilities or watch the video.


Stroke Treatment Inadequate in Many Cases

By Angela Griffith

Research presented at the American Stroke Association’s International Stroke Conference 2014 showed that although 81% of people in the United States lives within an hour’s drive of a hospital equipped to treat acute stroke, only 4% received tPA, a drug which can reduce disability if given within 3-4 hours of the first stroke symptom, and the only drug approved by the FDA to treat stroke.

Researchers reviewed the records of 370,000 Medicare stroke claims from 2011.  (Annually in the United States, 800,000 people suffer from stroke.)  The low percentage of patients receiving the recommended (and only) treatment for stroke is a significant impact to both the patient safety goal (because of the disability that could be avoided with proper treatment) and the patient services goal, because so many patients are not getting adequate treatment after a stroke.

There are many challenges involved in administering tPA within the recommended time frame.  Administration is ideally done within 3-4 hours of the first stroke symptoms, but faster is better.  As the study‘s lead author, Dr. Opeolu Adeoye, M.D., M.S. states, “Every 15-minute delay in getting treatment increases the odds of that patient not being able to go home.”

Although 4 out of 5 patients live within an hour’s drive of a designated stroke center, a hospital which is equipped to treat stroke (and not all hospitals are), that still leaves almost 20% who aren’t.  The drug tPA can’t be administered before imaging confirms the stroke and that it is a non-bleeding-type stroke as administering tPA to patients suffering from a bleeding-type stroke can cause harm.  Even after a patient arrives at a stroke center, delays in imaging and treatment could increase the time before tPA is administered to outside the window.  The study also found that 60% of hospitals did not administer tPA to stroke victims, though it is the only recommended treatment for acute stroke.

Many potential solutions are being studied and implemented to reduce the risk of stroke after disability.

For patients: the best way to reduce the risk of disability from stroke is to prevent having a stroke in the first place.  About 80% of strokes are preventable and due to risk factors, such as smoking or obesity.  Maintaining a healthy lifestyle can reduce the risk of stroke.  If you or a loved one suffers from a stroke, contact an ambulance, as the ambulance will be able to direct you to a designated stroke center.  If you are driving yourself, it’s worth it to go to a designated stroke center, even if that means “bypassing another hospital that isn’t set up to deliver the necessary therapy, ” says Dr. Adeoye.

For paramedics: because paramedics tend to see most stroke patients before they get to a medical center, the search is on for a drug that could be administered prior to imaging (unlike tPA) so that stroke treatment could begin prior to arriving at a medical center.  A study looked at administering intravenous magnesium in the ambulance, but found that it did not improve stroke-related disability.  However, if another drug can be found that would, researchers are hopeful, as the median time for receiving the stroke treatment by ambulance was 45 minutes after symptoms began, and 74% of patients began treatment within an hour.

For medical centers:  The American Heart Association/ American Stroke Association’s national quality initiative Target: Stroke℠ aims to reduce the time between stroke symptoms and treatment.  Since its initiation in 2010, the percentage of patients treated within 60 minutes or less from hospital arrival has increased from less than one-third to more than one-half.  Additionally, the average time from arrival to treatment dropped from 74 to 59 minutes. These faster treatment times have reduced the percentage of stroke patients who died in the hospital from 9.9% to 8.3%.  The improvements were seen in patients regardless of age, sex, or race.

Ideally, the implementation of these solutions – and many more that are in the works – will continue to reduce the risk of, and from, stroke.

To view the Outline, Cause Map and solutions related to inadequate treatment for stroke patients, please click “Download PDF” above.  Or click here to read more.

Concern about Quality of Medical Care for Inmates

By Angela Griffith

Those in the custody of law enforcement are almost completely dependent upon law enforcement for their basic needs.  One of these needs that is not always being met involves proper medical care, or even checks after the declaration of a medical emergency.   Per Dr. Ronald Shansky, a physician who performs court-ordered monitoring of inmate conditions for Milwaukee County, Wisconsin, failure to provide proper medical care is a failure to uphold constitutional obligations to those in custody.  After all, he says, “The inmate is completely dependent.  Unless the system creates the opportunity for the medical tests to be done, the medications to be provided, it’s not going to happen.”

In Milwaukee County, which was the subject of a recent investigative report by the Milwaukee Journal Sentinel, 18 people died in the custody of law enforcement in the county between 2008 and 2012.  Of these deaths, 10 were found to be related to improperly treated or monitored conditions.  By performing a detailed investigation of just one of these deaths, solutions that could reduce the risk of all custodial deaths due to improperly treated or monitored conditions can be incorporated.

We can perform this investigation by creating a Cause Map, or visual root cause analysis.  We begin with the specifics of one of the 10 cases of custodial death.  For this example, we’ll look at the death of Jeremy Cunningham.  Mr. Cunningham died the morning of June 22, 2011, while he was being held at the Milwaukee Secure Detention Facility for violation of parole.  Two important factors to note were that the inmate reported that he had alcohol and drugs in his system (taken within 8 hours) and that the inmate had a heart condition.

Next we determine the impact to the goals from the perspective of the Department of Corrections.  The inmate safety is impacted due to the death of a person in custody. Because of the constitutional obligation of law enforcement to care for those within their custody, the compliance goal is impacted.  Additionally, due to the insufficient treatment of the victim while in custody, the inmate services goal was impacted.

Beginning with the inmate safety goal, we can ask why questions to determine the causes of the impact to the goal.  The patient died because of a health issue that was not sufficiently treated.  Though the autopsy determined that the inmate died from cocaine poisoning, a pathologist who reviewed the results believes that alcohol withdrawal is more likely.  Because the cause of death is still under debate, we can use a “?” to indicate that it is not yet known (and more evidence is needed to determine the actual cause of death, though this is unlikely to occur).

Had the patient experienced the health issue but received treatment, he would have been less likely to die as a result.  Thus, the insufficient treatment from the prison staff is a cause of his death.  From available information, several opportunities were missed to assess the inmate’s health needs.  In other cases involving inmate deaths, an expectation of 30-minute check of prisoners is discussed, though it appears that requirement is not frequently being met.  This is likely because of chronic understaffing due to funding issues.  Even after the inmate’s roommate pressed the emergency call button when the inmate begin seizuring, nobody was sent to check on the condition of the inmate. (The emergency call button was pressed during the night, and the inmate was found dead in the morning.)  At the time of the death, there was no policy in place specifying what to do upon receipt of an emergency call, though the alcohol withdrawal instructions state that an ambulance should be called if an inmate experiences seizures.

Although the inmate had reported use of alcohol and cocaine within 8 hours before his incarceration, he was not monitored for withdrawal symptoms, although nurses had indicated monitoring was necessary.  Additionally, the prisoner did not receive any special care or instructions due to his heart condition.  It’s possible his heart condition wasn’t known – he died within 20 hours of entering the facility, which does not have an on-site medical practitioner, and prison medical records are delivered within 24-48 hours.

The failure of the system to provide adequate care to this inmate, as well as the 9 others who died in custody due to failure of monitoring or treatment has led to some changes being adopted by the Department of Corrections.  (Other changes are being forced by the legal system.)  These include posting notices on the doors of inmates who need extra attention, analyzing blood alcohol content upon arrival, and requiring an in-person evaluation to   respond to all emergency calls from within the prison. Hopefully these changes will reduce the failures that led to Mr. Cunningham’s death as well as some of the other deaths.

To view the investigation of Mr. Cunningham’s death, as well as a timeline outlining all 18 deaths in Milwaukee County law enforcement custody, please click “Download PDF” above.  Or click here to read more.

Norovirus Outbreak on Cruise Ship Sickens Over 600

By Kim Smiley 

A cruise ship has once again made national headlines for a negative reason.  A norovirus outbreak on Royal Caribbean’s Explorer of the Seas sickened nearly 700 hundred people during a cruise that ended on January 29, 2014.  Noroviruses are extremely unpleasant and cause extreme stomach cramps, vomiting and diarrhea, not exactly the stuff fantastic vacation memories are made of.  According to the Centers for Disease Control and Prevention (CDC) there have been 56 gastrointestinal outbreaks on cruise ships in the past five years, but this outbreak is notable because it was one of the largest in 20 years.

This incident can be analyzed by building a Cause Map, a visual format for performing a root cause analysis that intuitively shows the cause-and-effect relationships between the causes that contribute to an issue.  A Cause Map is built by asking “why” questions and documenting the answers. ( To view a high level Cause Map of this example, click on “Download PDF”.)

In this example, the initial source of the norovirus is not known and may not be able to be determined, but a Cause Map can still be helpful in understanding how the outbreak spread and how the outbreak impacts the goals of the company.  The CDC did investigate the outbreak, but it can be difficult to determine how the norovirus was brought onboard.   Noroviruses are common, especially during the January through April peak season for norovirus infections, and cruise ships need to have a plan to deal with sick passengers because simply preventing a norovirus from coming onboard isn’t realistic.

Once a person infected with a norovirus is onboard a cruise ship, the illness can spread quickly because is highly contagious.  Noroviruses can be transmitted by contact with an infected person, consuming contaminated food and even touching contaminated surfaces such as stair handrails.  Cruise ships, along with other confined spaces such as nursing homes, are particularly susceptible to fast spreading outbreaks of norovirus because there is a large number of people in a small space and it can be a challenge to isolate sick people.  Many cruise ships also serve meals buffet style which can pass the virus quickly to a large number of people.

The cruise ship did have a plan in place to help mitigate any outbreaks and the number of ill passengers was decreasing by the time the ship returned to port.  Sick passengers were isolated to their cabins and crew increased cleaning and sanitation of the ship during the cruise.  The ship was also given an especially thorough cleaning and extra sanitizing prior to departure of the next cruise.  In order to track and help cruise ships prevent outbreaks the CDC also runs a Vessel Sanitation Program, which monitors illness at sea and provides information about disease prevention.  If plan to take a cruise, the best way you can protect yourself is by frequently and thoroughly washing your hands with soap and water.

Visit our previous blogs if you are interested in learning more about other cruise ship examples:

Engine Room Fire Results in Cruise Ship Nightmare

Cruise Ship Loses Power

The Salvage Process of Costa Concordia